MAJOR

ARTERIAL OF THE

INJURY NECK Report OF

IN
THE

CLOSED HUMERUS

FRACTURE

of a Case
ISLE OF WIGHT, ENGLAND

E. H. J. SMYTH, A woman left miles

wrist humerus,

RYDE,

aged Soon

eighty-six after
and cyanotic

fell

in her
an

home
absent

sustaining seen
radial pulse.

a closed She

fracture doctor, was who sent

of the found

neck

of the twenty

humerus.

the accident
with

she was

by her family

the whole in forearm, of the left part The of the third

forearm

to be cold

to hospital,

away, where on arrival and hand. Radiographs

she had showed

signs of complete loss of arterial circulation a fracture of the neck and great tuberosity (Fig. injury cephalic brachial 1). an incision vein, and was made prolonged along the lower

with moderate displacement At operation five hours after the groove, axillary and preserving upper part the of the

delto-pectoral part

downwards.

of the

artery were exposed. the axillary artery was pulled laterally at the the anterior circumflex caught humerus.
of the

The main trunk of acutely kinked and point artery, of origin of which was of the a segment in was

between Distal
axillary

the fragments to this point,

trunk

length
the

was

seen

to

be

25 centimetres damaged, and

occluded by thrombus; brachial artery was by spasm. The anterior

below this point greatly narrowed circumflex artery

was ligated release of

The axillary

and divided, with immediate the kink in the axillary trunk.

artery was opened distal to

the thrombosed sucked out, with narrowed freed from trunk all

segment restoration of the surrounding brachial

and the of flow. artery soft

clot The was

structures

and its lumen was perfused solution. Flow was restored

with papaverine well below the attempts, the lumen, unwere findings appeared
The patients

injured area, but despite prolonged including injection of saline into the brachial relieved.
FIG.

The

artery spasm artery and

2

remained wound the

closed. Progress-A

Figures line
became

and

3 show

A radiograph of the fracture. just below the elbow, and the forearm, wrist and

at operation. of demarcation
gangrenous. hand

general carried

condition out, after

remained which her

poor. condition

Twelve improved

days

after and she

injury made

mid-brachial an otherwise

amputation good recovery.

was

DISCUSSION

Numerous have
508

instances in the recent

of vascular literature.

injuries This

complicating further case

fractures seemed
THE JOURNAL

and

surgical
of recording

operations
because
SURGERY

appeared

worthy
OF

BONE

AND

JOINT

MAJOR

ARTERIAL

INJURY

IN CLOSED

FRACTURE

OF

THE

NECK

OF THE

HUMERUS

509

Fin. 2 FIG. 3 Operative findings. Figure 2-The initial findings at operation : the anterior circumflex artery had been trapped and pulled forward by the fracture: there was a thrombosed segment of the axillary artery and. distally, spasm of the brachial arterial trunk. Figure 3-After release of the axillary artery, ligation of the anterior circumflex artery, arteriotomy and the removal of thrombus the spasm persisted in the brachial artery.

of

the

rarity
In

of

severe

injury
of 220

humerus.

a series

Morris, fracture, case of

Beall, nor

Roofand any injury of because was vascular

to the axillary artery in closed acute arterial injuries, 10 per cent de Bakey (1960) cited no case ofvascular of the axillary artery area around artery. the McQuillan artery was and axillary whole complicating

fractures of the neck of the in association with fractures, injury with a humeral neck Nolan (1968) described in a woman by arteriotomy its effects were one of

thrombosis

the the

fracture-dislocation found at operation

seventy-three,

in which

to be a mass

of fibrous tissue and thrombectomy In this case apparent those of thrombosis displaced circumflex remained repeated All diagnosis injury ofthe
necessary

ofprevious unsuccessful damage practitioner Two

mastectomy in relieving was inflicted

and radiotherapy. Treatment the ischaemia. at the moment of fracture and on arrival responsible

to the general total ischaemia. from anterior artery unrelieved instillation authorities of ischaemia

shortly afterwards; distinct factors were

at hospital the signs were for occluding the artery:

contusion, and spasm from kinking and distortion from the pull of the circumflex artery. Some of these factors were countered by anterior ligation combined with arteriotomy and removal of clot, but distal spasm despite restoration of a pulsating flow below vessel must the contused segment as and soon the and as a of papaverine and saline into the lumen. agree that exploration of the damaged has been made; and that the deep

is indicated be split

fascia

arterial

dealt with according to circumstances damaged segment and graft replacement.

in view

by suture, arteriotomy, endarterectomy In our case endarterectomy was and it is doubtful ifit would in any

or excision not considered case have been

ofthe

restored

distal

flow,

feasible because, according to Stiles (1965), this procedure is only possible when there exists a suitable plane of separation between intima and media, as found in arteriosclerosis or with longstanding thrombi. Resection-arteriectomy would have been the treatment of choice but was rejected owing to the patients age and poor general condition. Arterial spasm has recently been defined by Nolan (1968) as a response to violent

distortion,

a state

of affairs

vividly

illustrated missile

in this wounds.

case, Although

and

also

significant and

in view Nolan

of the (1968) cases The

incidence

of spasm

in high

velocity

McQuillan

only met with a single of traumatic ischaemia, condition Unfortunately instillation

VOL. 51 B,

instance of definite arterial this figure in all probability

spasm does

in their review not reflect the

of thirty-seven true incidence.

remains so often unrecognised there is still no uniformly

Seddon (1964)

as to its management.

of2
NO.

per cent
3,
AUGUST

papaverine,
1969

it is not more frequently explored. of relieving it, and authorities differ advised, in order of priority, incision of the deep fascia, and excision ofthe injured segment initiating the spasm.

only because successful means

510 He added : Let us hope Bonney (1963) and others

E. H.

J. SMYTH

that a completely futile sympathetic favoured instillation of heparin (1965) arterial rapid The
by injecting of its

block will not (1,000 units) into are

have been the lumen value rather they have

done. below in the than time

the obstruction, arterial fibrin,

to

but

as Eastcott

emphasised,

anticoagulants

of limited

circulation, because and in addition the

In support in tree worthy ofthis up occur haemophiliacs. is opened of trial because

thrombi consist stream is likely

Eastcott method it with simplicity. cited of

of platelets and lymphocytes to carry them away before

the interesting and fact that coronary

act.

contention

thrombosis

can arterial always

Mustard

saline,

segment

Bull (1962), in which the distal by segment between clamps, seems

SUMMARY

A case
humerus in

of

injury

of

the of

axillary eighty-six

artery

complicating Spasm

a closed was not

fracture relieved

of

the despite

neck

of repeated

the

a woman

is reported.

instillation
I am for the greatly two

of papaverine.
indebted illustrations to Mr

Gangrene
R. C. Cole, 2 and

developed
Chief 3. Instructor,

and

amputation
Department of

above
Naval

the elbow
Illustration,

was
H.M.S.

required.
Veri,on,

in Figures

REFERENCES Thrombosis of the Femoral Artery Complicating Fracture of the Femur. Journal of Bone 45-B, 344. EAsTcorr. H. H. G. (1965): The Management ofArterial Injuries. JournalofBone andJoint Surgery, 47-B, 394. MCQUILLAN, W. M., and NOLAN, B. (1968): Ischaemia Complicating Injury. Journalof Bone andfoiizt Surgery, 50-B, 482. MORRIS, G. C., BEALL, A. C., RooF, W. R.. and De BAKEY. M. E. (1960): Surgical Experience with 220 Acute Arterial Injuries in Civilian Practice. American Journal of Surgery, 99, 775. MUSTARD, W. T., and BULL, C. (1962): A Reliable Method for Relief of Traumatic Vascular Spasm. A,z,zals ofSurgery, 155, 339. NOLAN, B. (1968) : Vascular Injuries. Jour,zal of the Royal College of Surgeons of Ediizburgh, 13, 72. SEDDON, Sir H. (1964): Volkmanns Ischaemia. British Medical Journal, i, 1587. STILES, P. J. (1965): Closed Injuries of the Iliac Arteries. Journal of Bone and Joiizt Surgery, 47-B, 507.
BONNEY,

G. (1963):

and

Joint

Surgery,

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY